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Home My WebLink AboutBUSINESS PLAN 7/27/2007i VOWS X1969 u 5700 STOCI~ALE HWY. ;,~ a~0~~ ~~ ~ ~' ~~5~o O ~~ -~~~ ~/ ~ ~~~ a-; z VONS 1969 SiteID: 015-021-002863 Manager STEVE SHUBERT Location: 5700 STOCKDALE HWY City BAKERSFIELD BusPhorie: (661) 328-6950 Map 102 CommHaz Low' Grid: 34D FacUnits: 1 AOV: CommCode: BFD STA 11 EPA Numb: SIC Code:5411 DunnBrad:00-132-5034 Emergency Contact / Title Emergency Contact / Title STEVE SHUBERT / S TORE MANAGER LOSS PREVENTION / MANAGER Business Phone: (661) 328-6950x Business Phone: (626) 821-7545x 24-Hour Phone (626) 821-7545x 24-Hour Phone (626) 821-7545x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact MIKE CLIATT Phone: (626) 821-6192x MailAddr: PO BOX 513338 State: CA City LOS ANGELES Zip 90051-1338 Owner GILBARCO INC - CMS Phone: (303) 986-8011x Address PO BOX 22087 MAIL STOP F76 State: NC City GREENSBORO Zip 27420 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD €:.~^rd on my irqui~y of these individuais r,~~~~^ih~4 for obT?~nir-~~ ¢he information, I certify !spider aena{ty of laln~ that !have persona{iy e>c'r;1n~d ar;d ~,m fr_miiiar with the information sut:n~!+ted z~id believe the information is true, accufate, and complete. -i~~, ~ x~urv D a~~Z~- 6~ EI~~ ~ °~ -1- 07/16/2007 ,,~i1 F VONS 1969 SiteID: 015-021-002863 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP FREON R-22 P IH G 3100.00 LBS Low HELIUM F P IH G 582.00 FT3 Min CARBON DIOXIDE F P IH G 350.00 FT3 Min -2- 07/16/2007 ,.'i -3- 07/16/2007 F VONS 1969 SiteID: 015-021-002863 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME FREON R-22 Days On Site 365 Location within this Facility Unit Map: Grid: MOTOR RM CAS# 75-45-6 STATE T TYPE PRESSURE ~~ TEMPERATURE CONTAINER TYPE ~GaS I Pure Above Ambient I Ambient OTHER - SPECIFY AMOUNTS AT THIS LOCATION - Largest Container Daily Maximum Daily Average 3100.00 LBS 3100.00 LBS 3100.00 LBS HAZARDOUS COMPONENTS aWt. RS CAS# 100.00 Chlorodifluoromethane No 75456 tiHGE1tCL 1-~.~ JL" ~7.71~1J;1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies P IH / / / Low ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME HELIUM. Location within this Facility Unit FLORAL DEPT STATE TYPE PRESSURE _ Gas TPure ~-Above Ambient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 007-440-597 TEMPERATURE CONTAINER TYPE Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Co291~00rFT3 - Daily 582100m FT3 I Daily 291r00e FT3 nsiaylu~uu~ ~.vl~lrvlv~lvla ~Wt. RS CAS# 100.00 Helium No 7440597 t1E~GL-~ICL H. 7.7~J.51~1~1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min -4- 07/16/2007 F VONS 1969 ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME CARBON DIOXIDE Location within this Facility Unit SERVICE DELI STATE TYPE PRESSURE _ Gas TPure Above Ambient SiteID: 015-021-002863 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 124-38-9 TEMPERATURE CONTAINER TYPE Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Co175100rFT3 Daily 350100m FT3 I Daily 175r00e FT3 - r1t~~r~tcLVU~ ~ulnruivl;ivl5 %Wt. RS CAS# 100.00 Carbon Dioxide No 124389 riHGilttL H~51;S~1~1L"~1V'1"~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min -5- 07/16/2007 ~~ \ f. F VONS 1969 SiteID: 015-021-002863 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification Employee Notif./Evacuation 02/28/2006 AFTER THE LOCAL EMERGENCY RESPONSE PERSONNEL ARE NOTIFIED, YOU SHALL THEN NOTIFY THIS UNIFIED PROGRAM AGENCY AND THE OFFICE OF EMERGENCY SERVICES. t UlJ1.LV 1YV V11 . ~ L' V 0.1.U0. V1V11 Emergency Medical Plan 02/28/2006 KAISER STOCKDALE MEDICAL OFFICES OCCUPATIONAL CLINIC 3501 STOCKDALE HWY 661-398-5070 -6- 07/16/2007 ,~ F VONS 1969 SiteID: 015-021-002863 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention 02/28/2006 PRODUCTS CONTAINING HAZARDOUS CHEMICALS ARE MERCHANDISED ON SHELVES IN SUCH A MANNER AS TO PREVENT DAMAGE, BREAKAGE, OR SPILLAGE OF THE PRODUCT. INCOMPATIBLE CHEMICALS ARE SEPARATED BY DISTANCE AND/OR PARTITION TO AVOID ACCIDENTAL MIXTURE. 9 Release Containment 02/28/2006 IN THE EVENT OF AN INCIDENT, THE AREA WILL IMMEDIATELY BE EVACUATED OF CUSTOMERS AND UNTRAINED PERSONNEL. TRAINED MANAGERS WILL MITIGATE IF POSSIBLE OR CONTACT LOCAL OFFICALS FOR ASSISTANCE. Clean Up 02/28/2006 SMALL RELEASES WILL BE HANDLED BY TRAINED PERSONNEL. CHEMICALS WILL BE ABSORBED, PLACED IN APPROPRIATE CONTAINERS AND HANDLED BY A PROFESSIONAL CONTRACTOR. STORE WILL CONTACT CENTRAL DISPATCH AT 623-869-3110 AND/OR LOCAL AUTHORITIES. ~,_ v \.1tc1 itG .7VLLl VG L"]l.. 1.1 V0.l.l Vll -~- 0~/16/200~ ~. F VONS 1969 SitelD: 015-021-002863 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ aNcc:lal nuc.al.u~ Utility Shut-Offs ,_ ril.c r1.v~.c~..~tiVaii. wa~.c1. DU111A 111t~. Vl:~: u~Jalll.:y LC V C1 -8- 07/16/2007 ~r d F VONS 1969 SiteID: 015-021-002863 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 01/17/2007 ~ BRIEF SUMMARY OF TRAINING PROGRAM: TRAINING SHALL BE PROVIDED INITIALLY FOR ALL NEW EMPLOYEES; ANNUALLY, INCLUDING REFRESHER COURSES, FOR ALL EMPLOYEES. rayv ~ riciu iui r u~.utc vac nclu tui r ul.ulC U.5'C -9- 07/16/2007 ~' + VONS 1969 ___________________________________________ SiteID: 015-021-002863 + Manager STEVE SHUBERT Location: 5700 STOCKDALE HWY City BAKERSFIELD BusPhone: (661) 328-6950 Map 102 CommHaz High Grid: 34D FacUnits: 1 AOV: CommCode: BFD STA 11 EPA Numb: SIC Code:5411 DunnBrad:00-132-5034 Emergency Contact / Title Emergency Contact / Title STEVE SHUBERT / STORE MANAGER LOSS PREVENTION / MANAGER Business Phone: (661) 328-6950x Business Phone: (626) 821-7545x 24-Hour Phone (626) 821-7545x 24-Hour Phone (626) 821-7545x Pager Phone ( ) - x _ Pager Phone _, v. ( ) - x .. - _ , Hazmat Hazards: Fire Press ImmHlth Contact MARCELLA T GELMAN MS RD Phone: (626) 821-5608x MailAddr: PO BOX 513338 State: CA City LOS ANGELES Zip 90051-1338 Owner VONS A SAFEWAY CO Phone: (626) 821-5608x Address PO BOX 513338 State: CA City LOS ANGELES Zip 90051-1338 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif' d: RSs : No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG.C - COMM HOOD --: _ ~ ~ -~~ APR 0 7 2006 - - , - - ~~~~d on my inquiry of those individuals f~~p6nsibie far obtaining the information, I certify iahdar penalty of law that I have personally examined and am familiar with the information ~ubmitt d and b®II the information is true, i~. a o ~~ eta. r`li~'C.~ at ..e = -1- 03/23/2006 .. Y E, /~ / ~ .. THE CERTIFIED UNIFIED PROGRAM AGENCIES of ~ _ ~~~s~ UNIFIED PROGRAM (UP) FORM ~~, CITY OF EL SEGUNDO FIRE DEPARTMENT CITY OF GLENDALE FIRE DEPARTMENT ~~ pF ~O~ qH ~r '"'4 I ~ C'F C7 } ti" > ~~ V r 4}^ ''~j 1~ i ~S I ~. x., s '`~ . i . C,ylii=ORN~P COUNTY OF LOS ANGELES FIRE DEPARTMENT CITY OF SANTA FE SPRINGS FIRE DEPARTMENT ~~~~P MONIC9, 7 ~ o ~ ~ CITIES OF LONG BEACH AND SIGNAL HILL A JOINT POWERS AGENCY f ~ \``\ f. ~ ~ f - !' ~\ :~ -_ ~ .: CITY OF LOS ANGELES FIRE DEPARTMENT CITY OF SANTA MONICA ENVIRONMENTALPROGRAMS ~~ SHORT FORM ' ~ INTRODUCTION TO COMPLETION OF THE UNIFIED PROGRAM (UP) FORM TABLE OF CONTENTS INTRODUCTION A. What is a CUPA? B. Offices of CUPAs in Los Angeles County ............................................................................................................. -II- C. Participating Agencies of the LA County CUPA .................................................................................................. -III- D. Reporting Policy ................................................................................................................................................... -IV- E. What Do I Report? ................................................................................................................................................ -V- F. Basic Instructions .................................................................................................................................................-VI- G. Form Organization ............................................................................................................................................... -VI- H. Flow Chart ........................................................................................................................................................... -VII- 1. FACILITY INFORMATION SECTION A. Business Activities Page ......................................................................................................................................... -3- B. Business Owner/Operator Identification Page (FORMERLYOES FORM 2730) ................................................... -5- C. Consolidated Contingency Plan ............................................................................................................................ -7- II. HAZARDOUS MATERIALS SECTION A. Hazardous Materials Inventory -Chemical Description Page (FORMERLYOES FORM 2731) ...................... -21- B. Regulated Substance Registration (Cal ARP) (FORMERLYOES FORM 2735.6) .............................................. -23- 111. HAZARDOUS WASTE SECTION A. Hazardous Waste Generator Form ...................................................................................................................... -29- Note: The UP form was developed by the CUPA s of Los Angeles County as an alternative version of the Unified Program Consolidated Form (UPCF). Businesses have the option to use it or theUPCF adopted in state regulations. The CUPA or Participating Agency (PA) must accept the state UPCF and cannot require a business to use the alternative version developed by the CUPA. The CUPA and PA can require businesses to provide additional information on either the UPCF or a supplemental page to that document. (Reference: 27 CCR Section 15400.3 (d)) UP Form (1/2000 Short Version) I LAC4:UPFORMS3 THE CUPAs OF LOS ANGELES COUNTY INTRODUCTION TO COMPLETION OF THE UNIFIED PROGRAM (UP) FORM WHAT IS A CUPA? Senate Bill 1082, introduced by Senator Charles Calderon (D-Whittier) and passed in 1993, created the Unified Hazardous Waste and Hazardous Materials Management Regulatory Program (Unified Program), which requires the administrative consolidation of six hazardous materials and waste programs (Program Elements) under one agency, a Certified Unified Program Agency (CUPA). The Program Elements consolidated under the Unified Program are: • Hazardous Waste Generator and Onsite Hazardous Waste Treatment Programs (a.k.a. Tiered Permitting); • Aboveground Petroleum Storage Tank Spill Prevention Control and Countermeasure Plan (SPCC); • Hazardous Materials Release Response Plans and Inventory Program (a.k.a. Hazardous Materials Disclosure or "Community-Right-To-Know"); • California Accidental Release Prevention Program (Cal ARP); • Underground Storage Tank Program (UST); and, • Uniform Fire Code Plans and Inventory Requirements. The goal of the Unified Program is to create a more cohesive, effective and efficient program. Under the Unified Program, application and required submission forms are standardized and consolidated, inspections are combined where possible, annual fees for each program element are merged into a single fee system, and enforcement procedures are made more consistent. Local agencies administering one or more of the six Program Elements had the option to either apply for CUPA status with the California Environmental Protection Agency (Cal EPA) or retain their programs by becoming a Participating Agency (PA) under another CUPA's jurisdiction. Counties were required to apply for CUPA designation. Eight CUPAs in Los Angeles County received certification from Cal EPA to implement the CUPA program effective July 1, 1997 including the Cities of EI Segundo, Glendale, Long Beach/Signal Hill (a Joint Powers Agency), Los Angeles, Santa Fe Springs, Santa Monica, and Vernon, and the County of Los Angeles (LA Co CUPA). The LA Co CUPA implements the Unified Program in all unincorporated and incorporated areas of the County not within the jurisdiction of .the other seven CUPAs. (Note: The Los Angeles County Fire Department administers Hazardous Waste Programs in the cities of Los Angeles and Santa Monica as a Participating Agency.) Twelve cities and two County agencies entered into agreements and/or Memorandum of Understanding with the .Los Angeles County Fire Department to administer one or more of the Program Elements as Participating Agencies (PAs) to the LACoCUPA. The twelve City agencies include the Fire Departments of Alhambra, Burbank, Compton, Culver City, Downey, Gardena, Inglewood, Monrovia, Pasadena, Redondo Beach, South Pasadena, and Torrance. The two County Departments include the Department of Public Works and the Agricultural Commissioner. OFFICES OF CUPAs IN LOS ANGELES COUNTY EI Segundo Fire Department Santa Fe Springs Fire Department LA County Fire Department Offices 314 Main Street 11300 Greenstone Avenue 5825 Rickenbacker Road EI Segundo, CA 90245 Santa Fe Springs, CA 90670 Commerce, CA 90040 (310) 327-4311 (562) 944-9713 Glendale Fire Department 780 Flower Street Glendale, CA 91201 (818) 548-4030 City of Santa Monica Environmental Programs 200 Santa Monica Pier #1 Santa Monica, CA 90401 (310) 458-8228 Central District (323) 890-4107 West District (323) 890-4023 Data Unit (323) 890-4000 RMP Unit (323) 890-4035 Long Beach/ Signal Hill JPA Long Beach Health Department 2525 Grand Avenue Long Beach, CA 90815 (562) 570-4128 Los Angeles City Fire Department 200 N. Main Street, Room 970 Los Angeles, CA 90012 (213) 485-8080 UP Form (1/2000 Short Version) THE CUPAs OF LOS ANGELES COUNTY Vernon Environmental Health 4305 Santa Fe Avenue Vernon, CA 90058 (323) 583-8811 , Los Angeles County Fire Department Health Haz Mat Division 5825 Rickenbacker Road Commerce, CA 90040 (323) 890-4045 North County (818) 364-7120 14425 Olive View Dr. Sylmar, CA 91342 South Bay (310) 534-6270 24300-A Narbonne Ave. Lomita, CA 90717 San Gabriel Valley (626) 450-7450 5110 North Peck Rd. EI Monte, CA 91732 Southeast County (562) 790-1810 7300 Alondra Blvd. Paramount, CA 90723 LAC4:UPFORMS3 INTRODUCTION TO COMPLETION OF THE UNIFIED PROGRAM (UP) FORM LOS ANGELES COUNTY CUPA • PARTICIPATING AGENCIES ALHAMBRA FIRE DEPARTMENT JOHN KABALA Hazardous Materials Program 301 N. First Street Cal ARP Program Alhambra, CA 91801 (626) 570-3234 /FAX (626) 457-8961 MONROVIA FIRE DEPARTMENT DEREK YOUNG Hazardous Materials Program 141 E. Lemon Avenue Cal ARP Program Monrovia, CA 91016 (626) 303-3473 Ext. 542 /FAX (626) 358-1275 BURBANK FIRE DEPARTMENT DEVIN BURNS Hazardous Materials Program 311 E. Orange Grove Ave Cal ARP Program Burbank, CA 91502 UST Program (818) 238-3473 /FAX (818) 238-3483 COMPTON FIRE DEPARTMENT MARVIN PORTER Hazardous Materials Program 201 S. Acacia Cal ARP Program Compton, CA 90220 (310) 605-5670 /FAX (310) 632-8414 CULVER CITY FIRE DEPARTMENT KIM DOMBROWSKI Hazardous Materials Program P.O. Box 507 Cal ARP Program 9770 Culver Blvd. Culver City, CA 90232-0507 (310) 253-5937 /FAX (310) 253-5824 DOWNEY FIRE DEPARTMENT ROBERT ROWE Hazardous Materials'Program 11111 Brookshire Avenue Cal ARP Program Downey, CA 90241 (562) 904-7348 /FAX (562) 904-7270 GARDENA FIRE DEPARTMENT ROBERT NOLAN Hazardous Materials Program 1650 W. 162nd Street Cal ARP Program Gardena, CA 90247 (310) 217-9656 /FAX (310) 715-6070 INGLEWOOD FIRE DEPARTMENT DAVE COURTNEY Hazardous Materials Program 141 W. Regent St. Cal ARP Program Inglewood, CA 90301 (310) 412-5350 /FAX (310) 412-5673 PASADENA FIRE DEPARTMENT CALVIN E. WELLS Hazardous Materials Program 199 S. Los Robles Av. #550 Cal ARP Program Pasadena, CA 91101 UST Program (626) 405-4657 /FAX (626) 585-9164 REDONDO BEACH FIRE DEPARTMENT JOEL COSTER Hazardous Materials Program 401 S. Broadway Cal ARP Program Redondo Beach, CA 90277 (310) 318-0663 Ext. 2495 /FAX (310) 376-3407 SOUTH PASADENA FIRE DEPARTMENT RICHARD JENKINS Hazardous Materials Program 8i7 S. Mound Street Cal ARP Program South Pasadena, CA 91030 (626) 403-7300 /FAX (626) 403-7301 TORRANCE FIRE DEPARTMENT KEN HALL Hazardous Materials Program 3031 Torrance Blvd. Cal ARP Program Torrance, CA 90503 UST Program (310) 618-2973 f FAX (310) 781-7506 COUNTY OF LOS ANGELES AGRICULTURAL COMMISSIONER/ WEIGHTS & MEASURES Hazardous Materials Program BOB DONLEY or CINDY WERNER 12300 Lower Azusa Rd. Arcadia, CA 91006 (626) 575-5466 /FAX (626) 443-6652 LOS ANGELES COUNTY DEPARTMENT OF PUBLIC WORKS, WASTE MANAGEMENT DIVISION CARL SJOBERG UST Program 900 S. Fremont Avenue Alhambra, CA 91803-1331 (626) 458-3539 /FAX (626) 458-3569 NOTE: The LA Co CUPA implements the Unified Program in all unincorporated and incorporated areas of the County not within the jurisdiction of the seven City CUPAs. Each Participating Agency of the LA Co CUPA regulates the program listed in their jurisdictions. The Los Angeles County Department of Public Works administers the UST program in all areas of the LA County CUPA except for the cities of Burbank, Pasadena, and Torrance where the City Fire Department administers the UST program. The County of Los Angeles Agricultural Commissioner administers the Hazardous Materials program for agricultural business (farms and nurseries). UP Form (1/2000 Short Version) THE CUPAs OF LOS ANGELES COUNTY LAC4:UPFORMS3 I. FACILITY INFORMATION SECTION To be completed by all businesses, regardless of program type. Be advised that appropriate signatures must be provided on forms. This section includes: ~ BUSINESS ACTIVITIES PAGE Please complete this form first. This will help you to determine which other forms you are required to complete. ~ BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE All sections must be completed, including primary and secondary emergency contacts. ~ CONSOLIDATED CONTINGENCY PLAN All regulated businesses must complete the Cover Page, Section I (Business Plan and Contingency Plan), and a Site Map. Facilities with Underground Storage Tanks must also complete Section II (UST Emergency Response and Monitoring Plan). UNIFIED PROGRAM (UP) FORM BUSINESS ACTIVITIES Pa e 1 of _1 I. FACILITY IDENTIFICATION FACILITY ID # ~ EPA ID # (Hazardous Waste Only) 2 N/A BUSINESS NAME (Same as Facility Name of DBA-Doing Business As) s Vons #1969 II. ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, please submit the Business Owner/Operator Identification page. Does our facilit .. If Yes, lease com lete these a es of the UPCF.... A. HAZARDOUS MATERIALS Have on site (for any purpose) hazardous materials at or above 55 gallons for / HAZARDOUS MATERIALS liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include INVENTORY -CHEMICAL DESCRIPTION liquids in ASTs and USTs); or the applicable Federal threshold quantity for an RYES ^ NO 4 / CONSOLIDATED CONTINGENCY extremely hazardous substance specified in 40 CFR Part 355, Appendix A or PLAN (Section I and Site Map(s)) B; or handle radiological materials in quantities for which an emergency plan is / TRAINING PLAN required pursuant to 10 CFR Parts 30, 40 or 70? B. UNDERGROUND STORAGE TANKS (USTs) /UST FACILITY 1. Own or operate underground storage tanks? ^YES X NO 5 /UST TANK (one page per tank) 2. Intend to upgrade existing or install new USTs? ^YES X NO 6 /UST FACILITY /UST TANK (one per tank) /UST INSTALLATION - CERTIFICATE OF COMPLIANCE (one page per tank) 3. Need to report closing a UST? ^YES X NO 7 /UST TANK (closure portion one page per tank) C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above these thresholds: ---any tank capacity is greater than 660 gallons, or ^YES X NO g NO FORM REQUIRED TO CUPAs ---the total capacity for the facility is greater than 1,320 gallons? D. HAZARDOUS WASTE 1. Generate hazardous waste? / EPA ID NUMBER -provide at the top of ' ^YES X NO 9 this page. / As a generator, answer YES to Item E2b and complete Waste Generator Form. 2. Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC 25143.2)? ^YES X NO 10 / RECYCLABLE MATERIALS REPORT 3. Treat hazardous waste on site? ^YES X NO 11 / ONSITE HAZARDOUS WASTE TREATMENT -FACILITY / ONSITE HAZARDOUS WASTE TREATMENT -UNIT (one page per unit) 4. Treatme~t subject to financial assurance req ji~ements (for ^ YES X NO 12 / CERTIFICATION OF FINANCIAL Permit b Rule and Conditional Authorization . ASSURANCE 5. Consolidate hazardous waste generated at a remote site? ^ YES X NO 13 / REMOTE WASTE /CONSOLIDATION SITE ANNUAL NOTIFICATION 6. Need to report the closurelremoval of a tank that was classified as YES X NO 14 ^ / HAZARDOUS WASTE TANK CLOSURE hazardous waste and cleaned onsite? CERTIFICATION E. LOCAL REQUIREMENTS 15 1. REGULATED SUBSTANCES Have Regulated Substances (RS) including Extremely Hazardous Substances 15a In addition to Hazardous Materials (EHS) stored on site at greater than the threshold planning quantities ^YES X NO requirements, complete: established by the California Accidental Release Program (Cal ARP) ? / Regulated Substance Registration / Risk Mana ement Plan when re uired 2. OTHER REQUIREMENTS a. Have hazardous materials stored on site at or above a threshold amount 15b / Consult local CUPA or PA for added established by a CUPA's or PA's local ordinance? ^YES X NO reporting requirements. b. Required by a CUPA or PA to provide other information? 15c / Waste Generator Form (LA County) ^YES X NO OFFICIAL USE ONLY UP FORM HW HM ARP AST UST TP CUPA PA MAIL-OUT (4!2001 Short Version) 3 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 u~ti~~ ~2g~ UNIFIED PROGRAM (UP) FORM BUSINESS OWNER/OPERATOR IDENTIFICATION XNEWBUSINESS ^OUTOFBUSINESS ^AEVISE/UPDATE (EFFECTIVE 02/03/06) PAGE L OF ~ an I. IDENTIFICATION FACILITY ID# ~ BEGINNING DATE i°° 2006 ENDING DATE 2009 3 ears t01 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 VONS #1969 BUSINESS PHONE 661-328-6950 102 BUSINESS SITE ADDRESS 5700 STOCKDALE HIGHWAY io3 CITY BAKERSFIELD Gar CA ZIP CODE 93309 ios DUN & BRADSTREET 00-132-5034 106 SIC CODE (4 digit #) 5411 107 COUNTY LOS ANGELES 108 UNINCORPORATED ^ Yes ^ No 133a. BUSINESS OPERATOR NAME VONS A SAFEWAY COMPANY 109 BUSINESS OPERATOR PHONE 626-821-5608 110 II. BUSINESS OWNER OWNER NAME VONS A SAFEWAY COMPANY ~~~ OWNER PHONE 626-821-5608 112 OWNER MAILING ADDRESS P.O. BOX 513338 1i CITY LOS ANGELES 114 STATE CA 15 zIP coDE 900511338 "6 III. ENVIRONMENTAL CONTACT CONTACT NAME MARCELLA T. GELMAN M.S. R.D. 117 CONTACT PHONE 626-821-5608 118 CONTACT MAILING ADDRESS P.O. BOX 513338 119 cITY LOS ANGELES 120 STATE CA 121 zIP CODE 900511338 122 -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME STEVE SHUBERT 123 NAME LOSS PREVENTION 126 TITLE STORE MANAGER 124 TITLE LOSS PREVENTION MANAGER t2s BUSINESS PHONE 661-328-6950 125 BUSINESS PHONE 626-821-7545 i3o 24-HOUR PHONE 626-821-7545 126 24-HOUR PHONE 626-821-7545 '3t PAGER #N/A 127 PAGER #N/A 132 V. ADDITIONAL LOCALLY COLLECTED INFORMATION 133 NUMBER OF EMPLOYEES 202 133b FEDERAL TAX IDENTIFICATION NUMBER 381623900 133c MAILING/ BILLING INFORMATION ADDRESS SAFEWAY NASC MS 6516, TAX DEPARTMENT 133d CITY 133e STATE 1331 ZIP CODE 133g ATTN: ANGELA HERNANDEZ 133h PHOENIX AZ 85038-9096 Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATURE OF OWNE OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 ~ Y3 ~ NAME OF DOCUMENT PREPARER TERI DEIBERT-NASH 135 NAME OF SIGNER (print) 136 TITL OF SIGNER 137 OFFICIAL USE ONLY INSPECTOR HW HM DISTRICT INSPECTION DATE DIV BATT STA MAIL-OUT (4/2001 Short Version) 6 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 ri_ Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN COVER PAGE FACILITY IDENTIFICATION BUSINESS NAME 3 FACILITY ID # 1 VONS #1969 SITE ADDRESS 103 CITY 104 ZIP CODE 105 5700 STOCKDALE HIGHWAY BAKERSFIELD, CA 93309 The Consolidated Contingency Plan provides businesses a format to comply with the emergency planning requirements of the following three written hazardous materials emergency response plans required in California: • Hazardous Materials Business Plan (HSC Chapter 6.95 Section 25504 (b) and 19 CCR Sections 2729-2732), • Hazardous Waste Generator Contingency Plan (22 CCR Section 66264.52), and, • Underground Storage Tank Emergency Response Plan and Monitoring Program (23 CCR Sections 2632 and 2641). This format is designed to reduce duplication in the preparation and use of emergency response plans at the same facility, and to improve the coordination between facility response personnel and local, state and federal emergency responders during an emergency. Use the chart below to determine which sections of the Consolidated Contingency Plan need to be completed for your facility. If you are unsure as to which programs your facility is subject to, refer to the Business Activities Page. PROGRAMS SECTION(S) TO BE COMPLETED Hazardous Materials Business Plan (HMBP) Cover Page, Section I, and Site Map(s) Hazardous Waste Generator (HWG) Cover Page, Section I, and Site Map(s) Underground Storage Tank (UST) Cover Page, Sections I and II, and Site Map(s) HMBP, HWG, UST Cover Page, Sections I and II, and Site Map(s) A copy of the plan shall be submitted to your local CUPA and at least one copy of the plan shall be maintained at the facility for use in the event of an emergency and for inspection by the local agency. Describe below where a copy of your Contingency Plan, including the hazardous material inventories and Site Map(s), is located at your business: MANAGER'S OFFICE AT THE STORE AND AT 618 MICHILLINDA AVE., ARCADIA, CA 91007, FOOD SAFETY & ENV. AFFAIRS DEPT.. PLAN CERTIFICATION I certify under penalty of law that I have personally examined and I am familiar with the information provided by this plan and to the best of my knowledge the information is accurate, complete, and true. Printed Name of Owner/ Operator MARCELLA T. GELMAN, M.S., R.D. Title of Owner/Operator MANAGER-VONS FOOD SAFETY & ENVIRONMENTAL AFFAIRS Signature of Owner/ Op a r Date We appreciate the effort of local businesses in completing these plans and will assist in every possible way. If you have any questions, please contact your local CUPA or PA. OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY DIV BN STA OTHER DISTRICT CUPA PA Unified Program (UP) Form MAIL-OUT (4/2001 Short Version) 7 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN I. FACILITY IDENTIFICATION BUSINESS NAME 3 FACILITY ID # 1 VONS #1969 SITE ADDRESS 103 CITY 104 ZIP CODE 105 5700 STOCKDALE HIGHWAY BAKERSFIELD, CA 93309 II. EMERGENCY CONTACTS PRIMARY SECONDARY NAME 123 NAME 128 STEVE SHUBERT LOSS PREVENTION TITLE 124 TITLE 129 STORE MANAGER LOSS PREVENTION MANAGER BUSINESS PHONE 125 BUSINESS PHONE 130 661-328-6950 626-821-7545 24-HOUR PHONE 126 24-HOUR PHONE 131 626-821-7545 626-821-7545 PAGER # 127 PAGER # 132 Itl. EMERGENCY RESPONSE PLANS AND PROCEDURES A. 'Notifications Your business is required by State Law to provide an immediate verbal report of any release or threatened release of a hazardous material to local fire emergency response personnel, this Unified Program Agency (CUPA or PA), and the Office of Emergency Services. If you have a release or threatened release of hazardous materials, immediately call: FIRE/PARAMEDICS/POLICE/SHERIFF .PHONE: 911 AFTER the local emergency response personnel are notified, you shall then notify this Unified Program Agency and the Office of Emergency Services. Local Unified Program Agency: ((pfbl) 32~ - 394f State Office of Emergency Service: (800) 852-7550 or (916) 262-1621 National Response Center: (800) 424-8802 Information to be provided during Notification: • Your Name and the Telephone Number from where you are calling. • Exact address of the release or threatened release. :• Date, time, cause, and type of incident (e.g. fire, air release, spill etc.) • Material and quantity of the release, to the extent known. • Current condition of the facility. • Extent of injuries, if any. • Possible hazards to public health and/ or the environment outside of the facility. B. Emer enc. Medical Facilit List the local emergency medical facility that will be used by your business in the event of an accident or injury caused by a release or threatened release of hazardous material. HOSPITAVCLINIC: Kaiser Stockdale Med Offices Occupational PHONE NO: Clinic (661) 398-5070 ADDRESS: 3501 Stockdale Hw . CITY: ZIP CODE: BAKERSFIELD, CA 93309 OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY DIV BN STA OTHER DISTRICT CUPA PA MAIL-OUT (4/2001 Short Version) 9 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN C. Private Emer enc Res onse DOES YOUR BUSINESS HAVE A PRIVATE ON-SITE EMERGENCY RESPONSE TEAM? ^ Yes X No If yes, provide an attachment that describes what policies and procedures your business will follow to notify your on-site emergency response team in the event of a release or threatened release of hazardous materials. CLEANUP/DISPOSAL CONTRACTOR List the contractor that will rovide cleanu services in the event of a release. NAME OF CONTRACTOR: PHONE NO: Contact Central Dispatch in Phoenix Arizona -they will contact contractor. 626-869-3110 5 a.m. - 5 p.m.or 714-736-7212 after hours ADDRESS: N/A CITY: ZIP CODE: N/A N/A D. Arran ements With Emer enc Res onders If you have made special (i.e, contractual) arrangements with any police department, fire department, hospital, contractor, or State or local emergency response team to coordinate emergency services, describe those arrangements on the lines below: E. Evacuation Plan 1. The following alarm signal(s) will be used to begin evacuation of the facility (check all which apply): ~ Verbal ~ Telephone (including cellular) ~ Alarm System ~ Public Address System X Intercom ^ Pagers ^ Portable Radio ^ Other (specify): 2. ^D Evacuation map is prominently displayed throughout the facility. 3. ^D Individual(s) responsible for coordinating evacuation including spreading the alarm and confirming the business has been evacuated: Manager on duty. F. Earth uake Vulnerabilit Identify areas of the facility where releases could occur or would require immediate inspection or isolation because of the vulnerability to earthquake related ground motion. ^ Hazardous Waste/ Hazardous Materials Storage Areas ~ Production Floor ^ Process Lines ^ Bench! Lab ^ Waste Treatment ^ Other: Identify mechanical systems where releases could occur or would require immediate inspection or isolation because of the vulnerability to earthquake related ground motion. D Utilities D Sprinkler Systems D Cabinets D Shelves ~ Racks D Pressure Vessels ~ ~ Gas Cylinders ~ Tanks D Process Piping ~ Shutoff Valves ^ Other: MAIL-OUT (4/2001 Short Version) 10 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN G. Emer enc Procedures Briefly describe your business standard operating procedures in the event of a release or threatened release of hazardous materials: 1. PREVENTION (prevent the hazard) -Describe the kinds of hazards associated with the hazardous materials present at your facility. What actions would your business take to prevent these hazards from occurring? You may include a discussion of safety and storage procedures. PRODUCTS CONTAINING HAZARDOUS CHEMICALS ARE MERCHANDISED ON SHELVES IN SUCH A MANNER AS TO PREVENT DAMAGE, BREAKAGE, OR SPILLAGE OF THE PRODUCT. INCOMPATIBLE CHEMICALS ARE SEPARATED BY DISTANCE AND/OR PARTITION TO AVOID ACCIDENTAL MIXTURE. 2. .MITIGATION (reduce the hazard) -Describe what is done to lessen the harm or the damage to person(s), property, or the environment, and prevent what has occurred from getting worse or spreading. What is your immediate response to a leak, spill, fire, explosion, or airborne release at your business? IN THE EVENT OF AN INCIDENT, THE AREA WILL IMMEDIATELY BE EVACUATED OF CUSTOMERS AND UNTRAINED PERSONNEL. TRAINED MANAGERS WILL MITIGATE IF POSSIBLE OR CONTACT LOCAL OFFICIALS FOR ASSISTANCE. 3. ABATEMENT (remove the hazard) -Describe what you would do to stop and remove the hazard. How do you handle the complete process of stopping a release, cleaning up, and disposing of released materials at your facility? SMALL RELEASES WILL BE HANDLED BY TRAINED PERSONNEL. CHEMICALS WILL BE ABSORBED, PLACED IN APPROPRIATE CONTAINERS AND HANDLED BY A PROFESSIONAL CONTRACTOR. STORE WILL CONTACT CENTRAL DISPATCH AT 623-869-3110 - (OR AFTER HOURS 714-736-7212), AND/OR LOCAL AUTHORITIES. Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN MAIL-OUT (4/2001 Short Version) I 1 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 IV. Emergency Equipment 22 CCR, Section 66265.52(e) [as referenced by Section 66262.34(a)(3)] requires that emergency equipment at the facility be listed. Completion of the following Emergency Equipment Inventory Table meets this requirement. EMERGENCY EQUIPMENT INVENTOR Y TABLE 1. Equipment Cate or Equipment T e 3. Location * 4. Descri tion** Personal ^ Cartridge Respirators Protective, ^Chemical Monitoring Equipment (describe) Equipment, ^Chemical Protective Aprons/Coats Safety ^Chemical Protective Boots Equipment, Chemical Protective Gloves and ^Chemical Protective Suits (describe) First Aid Face Shields Equipment ^x First Aid Kits/Stations (describe) BACKROOM STANDARD FIRST AID KIT ^ Hard Hats !]Plumbed E e Wash Stations PORTER AREA Portable Eye Wash Kits (i. e. bottle pe) ^ Respirator Cartridges (describe) ~ Safety Glasses/Splash Goggles PORTER PLASTIC GOGGLES ^ Safety Showers ^ Self-Contained Breathing Apparatuses (SCBA) ^ Other (describe) Fire X Automatic Fire Sprinkler S stems THROUGHOUT THE BUILDING Extinguishing X Fire Alarm Boxes/Stations FRONT OF BUILDING Systems X Fire Extinguisher Systems (describe) SERVICE DELI/STOVE SYSTEMS ^ Other (describe) Spell ^ Absorbents (describe) COntr01 ^ Berms/Dikes (describe) Equipment ^ Decontamination Equipment (describe) -and ^ Emergenc Tanks (describe) Decontamination ^ Exhaust Hoods Equipment ^ Gas C tinders Leak Repair Kits (describe) ^ Neutralizers (describe) ^ Overpack Drums ^ Sumps (describe) ^ Other (describe) COmmUrllCatlOrlS ^Chemical Alarms (describe) and x Intercoms/ PAS stems THROUGHOUT THE BUILDING Alarm ^ Portable Radios Systems X Telephones FRONT DESK ^ Underground Tank Leak Detection Monitors ^ Other (describe) Additional Equipment (Use Additional Pages if Needed.) Use the Location Codes (LC) from the Site Map(s) prepared for your Contingency Plan. Describe the equipment and its capabilities. If applicable, specify any testing/maintenance procedure~ntervals. Attach additional pages, numbered appropriately, if needed. MAIL-OUT (4/2001 Short Version) 12 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 Unified Program (UP) Form CONSOLIDATED CONTINGENCY PLAN SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN V. EMPLOYEE TRAINING All facilities which handle hazardous materials must have a written employee training plan. A blank plan has been provided below for you to complete and submit. The items listed below are required per Health and Safety Code Section 25504 (c) and Title 19 Section 2732. Facility personnel are trained as follows: • Familiarity with all plans and procedures specified in the Contingency Plan. • Methods for Safe Handling of Hazardous Materials. • Safety procedures in the event of a release or threatened release of a hazardous material. • Use of Emergency Response equipment and supplies under the control of the business. • Procedures for Coordination with local Emergenc Response Organizations. Training shall be provided: • Initially for all new employees. • Annually, including refresher courses, for all employees. Note: These training programs may take into consideration the position of each employee. Additional training should include: :• Internal alarm/notification procedures. • Evacuation/re-entry procedures and assembly point locations. • Material Safety Data Sheet (MSDS) training including specific hazard(s) of each chemical to which employees may be exposed, including routes of exposure (i.e. inhalation, ingestion, absorption). VI. HAZARDOUS WASTE GENERATOR TRAINING If your business is a hazardous waste generator, you are required to provide training in hazardous waste management for all workers who handle hazardous waste at your site (22 CCR §66265.16). You are also required to document training. The items below are required. EMPLOYEE TRAINING • Facility personnel will successfully complete training within six months after the date of their employment or assignment to a facility or to a new position at a facility. :• Em to ees will not handle hazardous wastes without su envision until trained. TRAINING DOCUMENTATION The owner or operator must maintain the following documents and records at the facility: • Job title for each position at the facility that is related to hazardous waste management, and the names of the employee(s) filling the position(s). :• Description for each position listed above (must include required skill, education, or other qualifications as well as duties of employees assigned to the position. • Description of type and amount of both introductory and continuing training given to each employee. • Records that document that the requirements for training or job experience have been met. :• Current employees' training records (to be retained until closure of the facility). • Former emplo ees' trainin records (to be retained at least three ears after termination of emplo ment). MAIL-OUT (4/2001 Short Version) 13 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 II. HAZARDOUS MATERIALS SECTION To be completed by all businesses that handle hazardous materials and/or regulated substances (including extremely hazardous substances) Be advised that appropriate signatures must be provided on forms. This section includes: ~ HAZARDOUS MATERIALS INVENTORY FORM - CHEMICAL DESCRIPTION One chemical per page. Make photocopies as necessary. CAS Numbers must be provided for each chemical and hazardous component. To obtain the CAS#, refer to the chemical's MSDS (Materials Safety Data Sheet), or contact the chemical's manufacturer, or the Chemical Abstracts Service at (614) 447-3600. Facilities reporting chemicals subject to EPCRA (the Federal Emergency Planning and Community Right-to-Know Act) reporting thresholds must sign each page for each EPCRA reported chemical. For more information on EPCRA, contact US EPA at (800) 535-0202 or visit US EPA's EPCRA WebSlte at http://www.epa.gov/opptinr/tri/. REGULATED SUBSTANCE REGISTRATION FORM One chemical per page. Make photocopies as necessary. EGULATED MAIL-OUT (412001 Short Version) THE CUPAs OF LOS ANGELES COUNTY SUBSTANCE LIST 16 REVISED LAC4 UPFORMS3 ,~- BAKERSFIELD HAZARDOUS MATERIALS UNIFIED PROGRAM ~ California Hazardous Material Inventory Form -Chemical Description Page (1) I X ADD ^ DELETE ^ REVISE PAGE (2) 1~ OF (3) BUSINESS NAME (4) VONS #1969 CHEMICAL LOCATION (5) MOTOR ROOM MAP # (6) GRID # (7) CHEMICAL NAME (8) ~ FREON R-22 COMMON NAME (9) I FREON CAS # (10) 75-45-6 TRADE SECRET (11) ^ Y X N * EHS (12) ^ Y X N * IF EHS BOX IS "Y" ALL AMOUNTS MUST BE IN LBS FIRE CODE (13) NON-FLAMMABLE GAS I HAZARD CLASSES * COMPLETE BLOCK 13 IF REQUESTED BY THE LOCAL FIRE CHIEF - REFER TO INSTRUCTIONS. TYPE (14) X PURE ^ MIXTURE ^ WASTE RADIOACTIVE (15) ^ Y X N (i6) PHYSICAL STATE (17) ^ SOLID ^ LIQUID X GAS CURIES FED HAZARD (18) ^ FIRE ^ REACTIVE X PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH CATEGORIES CODEE WASTE (19) None UNITS (22) R'LBSL TONS MAX DAILY AMT (23) 3100 DAYS ON SITE (20) 365 *IF EHS, enter amounts in LBS below. AVG DAILY AMT (24) 3100 LARGEST (21) 3100 ANNUAL WASTE AMT (25) N/A CONTAINER X LBS STORAGE (26) ^ ABOVE GROUND TANK ^ CAN ^ BOX ^ TANK WAGON CONTAINER ^ UNDER GROUND TANK ^ CARBOY CYLINDER ^ RAIL CAR ^ TANK INSIDE BUILDING ^ SILO ^ GLASS BOTTLE X Machinery ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ OTHER ^ PLASTIC/NONMETALLIC DRUM ^ BAG ^ TOTE BIN PRESSURE (27) ^ AMBIENT X ABOVE AMBIENT^ BELOW AMBIENT STORAGE STORAGE (28) X AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC TEMPERATURE 29 % WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS # 1 100% Chlorodifluoromethane ^ Y X N 75-45-6 2 ~ ^Y ^N 3 ~ ^Y ^N 4 ~ ^Y ^N 5 ~ ^Y ^N ADDITIONAL LOCALLY COLLECTED INFORMATION FOR OFFICIAL USE ONLY ID # OES Form 2730(11/94) FRM-INV.DOC [Revised 9-96] ' BAKERSFIELD HAZARDOUS MATERIALS UNIFIED PROGRAM California Hazardous Material Inventory Form -Chemical Description Page (1) X ADD ^ DELETE ^ REVISE PAGE (2) ~ OF (3) BUSINESS NAME (4) ~ VONS #1969 CHEMICAL LOCATION (5) I SERVICE DELI MAP # (6) l GRID # (7) CHEMICAL NAME (8) COMMON NAME (9) CAS # (10) FIRE CODE (13) HAZARD CLASSES * TRADE SECRET (11) ^ Y X N * EHS (12) ^ Y X N * IF EHS BOX IS "Y" ALL AMOUNTS MUST BE IN LBS * COMPLETE BLOCK 13 IF REQUESTED BY THE LOCAL FIRE CHIEF -REFER TO INSTRUCTIONS. TYPE (14) X PURE ^ MIXTURE ^ WASTE RADIOACTIVE (15) ^ Y X N (16) PHYSICAL STATE (17) ^ SOLID ^ LIQUID X GAS CURIES FED HAZARD (18) ^ FIRE ^ REACTIVE X PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH CATEGORIES CODEE WASTE (19) None UNITS (22) S AL ~ ONS MAX DAILY AMT (23) 350 CB T DAYS ON SITE (20) 365 *IF EHS, enter amounts in LBS below. AVG DAILY AMT (24) 175 LARGEST (21) 175 ANNUAL WASTE AMT (25) N/A CONTAINER ^LBS STORAGE (26) ^ ABOVE GROUND TANK ^ CAN ^ BOX ^ TANK WAGON CONTAINER ^ UNDER GROUND TANK ^ CARBOY X CYLINDER ^ RAIL CAR ^ TANK INSIDE BUILDING ^ SILO ^ GLASS BOTTLE ^ ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ OTHER ^ PLASTIC/NONMETALLIC DRUM ^ BAG ^ TOTE BIN PRESSURE (27) ^ AMBIENT X ABOVE AMBIENT^ BELOW AMBIENT STOR;4G E STORAGE (28) X AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC TEMPERATURE 29 % WT 1 2 I~ 3 4 5 I I 30 HAZARDOUS COMPONENT N/A 31 EHS ^Y ^N . ^Y ^N ^Y ^N ^Y ^N ^Y ^N ADDITIONAL LOCALLY COLLECTED INFORMATION FOR OFFICIAL USE ONLY ID # OES Form 2730(11/94) FRM-INV.DOC jRevised 9-96j SANTA BARBARA COUNTY HAZARDOUS MATERIALS UNIFIED PROGRAM California Hazardous Material Inventory Form -Chemical Description Page (1) X ADD ^ DELETE ^ REVISE I PAGE (2) ~ OF (3) BUSINESS NAME (4) ~ VONS 1969 CHEMICAL LOCATION (5) I FLORAL DEPARTMENT MAP # (6) GRID # (7) CHEMICAL NAME (8) HELIUM TRADE SECRET (11) ^ Y X N COMMON NAME (9) HELIUM 'EHS (12) ^ Y X N CAS # (10) 007 440 597 " IF EHS BOX IS "Y" ALL AMOUNTS MUST BE IN LBS FIRE CODE (13) I NON-FLAMMABLE GAS HAZARD CLASSES' COMPLETE BLOCK 13 IF REQUESTED BY THE LOCAL FIRE CHIEF -REFER TO INSTRUCTIONS. TYPE (14) X PURE ^ MIXTURE ^ WASTE RADIOACTIVE (15) ^ Y X N (16) PHYSICAL STATE (17) ^ SOLID ^ LIQUID X GAS CURIES CATEGORIES (18) I ^ FIRE ^ REACTIVE X PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH CODEE WASTE (19) None UNITS (22) B LBS ~] TONS MAX DAILY AMT (23) 582 (2 cylinders) DAYS ON SITE (20) 365 'IF EHS, enter amounts in LBS below. AVG DAILY AMT (24) 291 (1 cylinders) CONTASNER (21) 291 (1 cylinder) ^LBS ANNUAL WASTE AMT (25) N/A STORAGE (26) CONTAINER ^ ABOVE GROUND TANK ^ CAN ^ BOX ^ TANK WAGON ^ UNDER GROUND TANK ^ CARBOY X CYLINDER ^ RAIL CAR ^ TANK INSIDE BUILDING ^ SILO ^ GLASS BOTTLE ^ ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ OTHER ^ PLASTIC/NONMETALLIC DRUM ^ BAG ^ TOTE BIN PRESSURE (27) : ^ AMBIENT X ABOVE AMBIENT^ BELOW AMBIENT STORAGE TEMPERATURE (28) X AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC 29 /o WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS # 1 o N/A ^ Y ^ N 2 ~ ^Y ^N 3 ~ ^Y ^N 4 ~ ^Y ^N .. 5 ~ ^Y ^N ADDITIONAL LOCALLY COLLECTED INFORMATION FOR OFFICIAL USE ONLY ID # OES Fortn 2730(11/94) FRM-INV.DOC [Revised 9-96] t~"St;'~t ' ~4trf' - :it~ (q.Y„`,. ~ - ~.. .Y 6 r 'd4'. a 'f~~ !;< __.;r~.. 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BAKER5f1ELQ, CA E9n uzfle - tlreke nd Cc vd r. . Stry c Wal at lal at~+cls b n! vhndaws. .On!E AO risfJ/i.HO7'd'.Yarteidad, rcy,rt+r oorrsr. •Au;s'I,ne vane - Cfrcktc+Msstds, • Evtrww -b ba7f ry a rlyAimArucled to do so. lko+L•Ys eny. • Be preyared for sitcrsttda. ROCK AREA RELOCATION AAEA F ~ ~N~ D~\~ Hte Erlinauizlters ~j Te Kam ~ rte aaixjueM.r. ~ Z1 P • Pul Va pin ~ 4-• A • Ain al IAo DJL9 el IAO file m S • Syueero IAe trig4es Asnd6 F~.. S • S..srPham+iS:-co+.L ~ Aa su~mrw.+n e~fires anrldEt~o(llat'r tits m m W edicel •Sl+y tsYnand yadlertAa irllarrralrin. m - 4a19-t-1. • [[s*tll ya. reef and ttls ycul k ea5 u Oa+eAne IAe urr r6Ka:y sifualiun. Adir.~leG,• anpt~a<s Mrte ettc~arcy •v! a:41c~• ararst+nm. As+L'1;`e Ytdrn to C~ N gree N+l yc v Gr a Ueinsd Haialdous Material . 17d3ylov +wt:e nis+r. •ISErr12'l RJtM+7t In.01•:EQ.ttryllrl -11 (t (YtE d• ir! tVt la Vn vrn:<ra1H ell+ +A~ I,E+l, OIAC/n o VL Asse 1lAoce v,Ao cf1 ervl E Xf0 on W:r ar r • Ref!xnktm frrN nd. asnng,dnnUng ; nd olp4/~ng [ o4IIti•M3 Civil Disorder •NaUyyaw-{~rrv~n.. Rr rt cinr/.AinCobv)i ng -6a nel bacorm a sfeeiNer. .Oo naNirr/to orrtcganaa Le<kruwoalns •p..-rir l~r~rri.VLnt:trti potnpc,a ry.r rvis!r. 8ornb hl-eal • Oe n<1 ~c.ntc. • Ifanly your tuyc r.uar. . Your ,t(ernisal owl npfr M u r:. r.!! kr n It:-nni Duns. I N LE,xnll.; P, =~nuy Ernergrnoy E•,1. -'~ fire-Err.Irel~i:hw~ 1~ .:,, rn<:ar Sod CII v::a U ~ I O m m f-+ I Cl ti~„~.w, 3~ .~ ~ LoL ~ r--n: ~ L ~~~ m m~ ~° o ~~ ~ ~ l~ 00 5700 Stockdalc Highway, Bakersfield, CA 93309 Store Entrances and Exits o ~ D VONS 9TOHE ~ 19e9 dT00 3TOClKDA1.E FIl~IKAY Fire Extinguishers ! Gcneralor ~ t Z B~SFIELD, CA f Fire Sprinkler Valvc Refrigeration Controls f [=,r~o•~` /QA t. ~~a..~,.~M ~ m ,_, ~ifJt~lE +881-92650 • Gas Valve ~ Powcr Panefs ~ _~ ,, ., D ~ I m i m m m N A W ~~ m m UNIFIED PROGRAM (UP) FORM REGULATED SUBSTANCE REGISTRATION THIS PAGE IS TO BE COMPLETED FOR A STATIONARY SOURCE THAT HANDLES A REGULATED SUBSTANCE (RSl IN A ,. PROCESS AT OR ABOVE THE THRESHOLD QUANTITY. REGULATED SUBSTANCES (INCLUDING FEDERAL LISTED AND STATE LISTED EXTREMELY HAZARDOUS SUBSTANCES) MUST BE REGISTERED FOR THE PURPOSE OF COMPLYING WITH THE Cal ARP (CALIFORNIA ACCIDENTAL RELEASE PREVENTION) PROGRAM. THE OWNER OR OPERATOR SHALL COMPLETE A HAZARDOUS MATERIALS INVENTORY FORM AND A REGISTRATION FOR EACH REGULATED SUBSTANCE PER EACH PROCESS. BUSINESS NAME 3 NO REGULATED SUBSTANCES ON SITE FACILITY ID# 1 EPA ID # 2 PROGRAM LEVEL ^ 1 ^ 2 ^ 3 246a NAME OF CORPORATE PARENT COMPANY 246b DUN & BRADSTREET 106 PERSON RESPONSIBLE FOR RMP (First Name, Last Name) 246c TITLE 246d LATITUDE 246e LONGITUDE 246f PROCESS SIC 107a DOES THE FACILITY HAVE SUBSTANCES LISTED IN 40 CFR 355 208 APPENDIX A (EHS)? ^YES ^ NO DO ANY PROCESSES REQUIRE A CLEAN AIR ACT 246g TITLE V OPERATING PERMIT ? ^YES ^NO IS FACILITY SUBJECT TO 29CFR 1910.119/CCR 8 SEC 246h 5189 PSM ? ^YES ^ NO LAST SAFETY INSPECTION 2461 DATE AGENCY CHEMICAL NAME 205 CAS# 209 MAXIMUM DAILY AMOUNT 218a POUNDS 22ta PROCESS DESCRIPTION 246j PRINCIPAL EQUIPMENT 246k CERTIFICATION I, the owner or operator of the aforementioned business, hereby certify that the registration information provided above is true, accurate, and complete to the best of my knowledge based upon reasonable inquiry. 1 am fully aware that this certification executed on the date indicated below is made under penalty of perjury under the laws of the State of California. OWNER/OPERATOR NAME 2461 OWNER/OPERATOR TITLE 246m OWNER/OPERATOR SIGNATURE DATE 246n OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY DIV BN STA OTHER DISTRICT CUPA PA MAIL-OUT (4/2001 Short Version) 20 REVISED LAC4 THE CUPAs OF LOS ANGELES COUNTY UPFORMS3 UNIFIED PROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmentall Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME q p, ~ ~ INSPE TION D TE 1 ~ ~ INSPECTION TIME vvr~l j I (~O ! 1. d~ t 4- ADDRESS PHONE No. No. of Employees S 7dy 5-~'z~c~t.n Awe ~.,~ ------------ -._......-----_._--_----._...-- G FACILITYCONTACT ~ -n-R-v Business ID Number 15-021- ~~/ Section 1: Business Plan and Inventory Pnagram ,,.Routine ^ Combined ®Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection C ~ \V=Vioatonnce~ OPERATION COMMENTS ^ ^ APPROPRIATE PERMIT ON HAND N~ ~ arJJZra ~T St'T"L'- CTU fS~ StsVT~ ^ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE ''~ ~~ y... At C.C--f~ ^ VISIBLE ADDRESS ~/ &l ^ CORRECT OCCUPANCY ~ - - -1- --- ~J ^ ---------- ----------- ------- -----... _ _ - VERIFICATION OF INVENTORY MATERIALS -----...._..-- -- - - ,~`~t.ldy~ ---- _ __ -------_.....------- --- - --- ---- -- - - -- . _ ._ _ ._.__ _ . _ ... LrJ ^ VERIFICATION OF QUANTITIES ~~j ( GF' ~ "Z. -J----.. ~f ^ .--------------------- ---------...._......--- - VERIFICATION OF LOCATION ------------ ~Lp(j,J~L -------__ -------._.......-------...---._...._.. ~.rp~ ~„ ~~ ~`~~;~. ---..__..__..__ --- jW~ ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITYE Ll ^ VERIFICATION OF HAT MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES 9!! ^ EMERGENCY PROCEDURES ADEQUATE I - -- - - - - ------i- ----- - --_._... __------- ------ --... - _ __ ... ___ _- ---- ^ CONTAINERS PROPERLY LABELED ® ^ HOUSEKEEPING ^ FIRE PROTECTION .t/J'~- ^ SITE DIAGRAM ADEQUATE & ON HAND C9f~r~`+~'~n cJ~ /~/S p ANY HAZARDOUS WASTE ON SITE?: ^ YES ,~..NO EXPLAIN: QUESTIONS REGARDING THIS INSPECTIONS PLEASE CALL US AT ~C6'I~ 328-3979 ~ ~ ~Ls Inspector Badge No., usiness White -Environmental Services Yellow - Stetgn Copy Pink -Business C